Nokea
A 16-year-old male client who has been treated in the past for a seizure disorder is admitted to the hospital. Immediately after admission, he begins to have a grand mal seizure. Which action should the nurse take?
- A. Obtain assistance in holding him to prevent injury.
- B. Observe him carefully.
- C. Call a CODE.
- D. Place a padded tongue blade between the teeth.
Correct Answer: B
Rationale: During a grand mal seizure, the priority action for the nurse is to ensure the safety of the client. Observing the client carefully allows the nurse to monitor the seizure activity, the client's breathing, and any signs of distress without interfering with the seizure process. Restraining the client or placing objects in the mouth can lead to injury and should be avoided. Calling a CODE is not appropriate for a seizure as it is a normal response to the client's condition.
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The caregiver is being educated by a healthcare provider about the use of a metered-dose inhaler (MDI) for their 8-year-old child with asthma. Which statement by the caregiver indicates a need for further teaching?
- A. I will shake the inhaler before each use
- B. My child should breathe in quickly after pressing the inhaler
- C. I should wait a minute between puffs
- D. We should use a spacer with the inhaler
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What suggestion should the nurse provide to prevent diaper rash in a 4-month-old infant as requested by the mother?
- A. Generously powder the baby's diaper area with talcum powder at each diaper change to promote dryness.
- B. Wash the diaper area every 2 hours with soap and water to help prevent skin breakdown.
- C. Use a barrier cream, such as zinc oxide, which does not have to be completely removed with each diaper change.
- D. Place a cloth diaper inside the disposable diaper for overnight periods when increased wearing time is likely.
Correct Answer: C
Rationale: Using a barrier cream like zinc oxide forms a protective layer on the skin, creating a barrier against irritants and moisture, thus helping to prevent diaper rash. Unlike other options, barrier creams do not need to be completely removed at each diaper change, allowing the skin to remain protected between changes.
The practical nurse is reinforcing information about Lyme disease prevention with a client who is preparing for a camping trip with family. Which statement by the client informs the nurse that the client understands the instruction?
- A. I'll make sure my son wears dark clothing on his hike.
- B. I'll get a prescription for amoxicillin to take with us.
- C. We should all get the Lyme disease vaccine before our trip.
- D. We will wear long pants and long-sleeved shirts in the woods.
Correct Answer: D
Rationale: The correct answer is D. Wearing long pants and long-sleeved shirts is an effective preventive measure against tick bites, which reduces the risk of contracting Lyme disease. This attire helps to minimize skin exposure to ticks, thereby decreasing the chances of a tick attaching and transmitting the disease-causing bacteria.
The caregiver is caring for a 2-month-old infant with a diagnosis of bronchiolitis. Which assessment finding would be most concerning to the caregiver?
- A. Nasal flaring and grunting
- B. Coughing and wheezing
- C. Poor feeding and irritability
- D. Increased respiratory rate
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The parents of a 3-year-old boy who has Duchenne muscular dystrophy (DMD) ask, 'how can our son have this disease? We are wondering if we should have any more children.' What information should the nurse provide these parents?
- A. This is an inherited X-linked recessive disorder, which primarily affects male children in the family.
- B. The male infant had a viral infection that went unnoticed and untreated, leading to muscle damage.
- C. The lack of the protein dystrophin in the mother can impact the muscle groups of males.
- D. Damage to the spinal cord due to birth trauma from a breech vaginal birth weakens the muscles.
Correct Answer: A
Rationale: The nurse should inform the parents that Duchenne muscular dystrophy is an X-linked recessive disorder, which primarily affects male children in the family. This genetic condition is caused by a mutation in the dystrophin gene located on the X chromosome. Females are usually carriers of the gene mutation and may pass it on to their sons. Daughters of carrier mothers have a 50% chance of being carriers themselves. Understanding the genetics of DMD can help the parents make informed decisions about family planning and genetic counseling.